The Medical College of Wisconsin-Milwaukeee Campus Class of 2023 graduated on May 19, 2023. I have always found the transition from medical school to residency to be a fascinating inflection point. I wrote years ago that, although we refer to these ceremonies as "commencements," these near-graduates have commenced many times already.
This year's ceremony was particularly wonderful for me. My medical school classmate and friend, Julie Freischlag, MD, FACS, FRCSEd(Hon), DFSVS was the speaker and I helped hood her for her honorary degree. When I think of her career trajectory and accomplishments, it is hard to believe we started in the same place. Way to go, Julie!
I have attended many graduation ceremonies over the years, always wondering what I might say that would make a difference to the graduates, A few years ago, I wrote the speech that contains a distillation of some of the important lessons I have learned along the way. I am reprinting below the medical school graduation speech I would give.
[Overly kind introduction...Very light applause...Papers shuffling...People looking at their phones...]
Ladies and Gentlemen, distinguished visitors, proud family members, parents, and graduates:
No matter how hard I try, I cannot remember a commencement address entitled, “Knowing and Doing” that Harriet Waltzer Sheridan, PhD delivered at my medical school graduation in 1980. She was a beloved, creative teacher at Brown University; her own struggles with cancer shaped her understanding of literature, the humanities, and medicine. Glowing biographies appear online and were recorded in the yellowed program my mother saved from that day. I know I heard her lecture; I only wish I could remember even one thing that she said. I’d bet it was wonderful.
Maybe my lack of recall is an unfortunate consequence of being in the presence of her genius on a day when my brain was already packed full. I don’t know. You students, of course, have the same predicament. Except the part about me being a genius.
The ceremonial events today might fade, but I guarantee you will remember encountering sheer joy after the recessional, out in the lobby where you will experience waves of emotion with your friends and family. I remember being overwhelmed, sharing tears and laughter with my wife, our families, and my classmates. That has stuck with me for all these years and I would bet that is what you will remember when you look back on today.
Advice given during commencement speeches has a very short half-life. At graduation, there are the obligatory word of congratulations, the plea to appreciate the journey, and platitudes about opportunities that stretch to the horizon. In the interest of time, let’s skip that part other than to say, “Congratulations! Smell the roses! and The sky’s the limit!” There. Done.
In the off-chance you remember any of this, I do not plan to provide answers to medicine’s burning questions. Rather than answers, I hope to equip you with questions. If you are still listening, you will hear three questions: one to ask every patient, one to ask yourself, and one that you should regularly review with a mentor.
First, a question to ask every patient:
Is there anything else you would like to talk about today?
In my practice, I have a cancer survivor who speaks agonizingly slowly. All. The. Time. Loooong, monotonous, convoluted questions. This has continued for years and our routine is unchanging. I complete the exam, check his labs, and pronounce him cancer-free. He is grateful, then has two more questions. Then another one. And another.
Years ago, not long after I began following him, a study appeared that evaluated communication between physicians and patients. The authors confirmed that doctors take control of encounters far too early, often denying patients the opportunity to bring up their own concerns. The doctors interrupted their patients after a mean of only 23 seconds.
The solution? Guess what? Office visits are no longer when the doctors repeatedly asked, “Is there anything else?” The patients felt heard.
Did the approach work with my patient? Well, sort of. But it forever changed the way I talk to patients in clinic and at the bedside. That’s a good thing.
Here’s a second question; this is the one you should ask yourself:
What else might it be?
This one comes from Jerome Groopman, a pediatric oncologist and New Yorker contributor. In his book, How Doctors Think, he recalls his own debilitating hand disorder. If he applied too much pressure to his right hand it became red and he developed excruciating pain in his wrist. He saw several Boston hand specialists over a number of years, each of whom came up with a different diagnosis. How could that happen?
Groopman compares most clinical decision-making to a branching tree; “yes-no” arrows point from box to box to box until the algorithm takes the clinician to a diagnosis. That approach works great much of the time.
Groopman points out, however, that cases that require “outside the box” thinking necessitate non-algorithmic thinking. The algorithm is actually a problem in those situations.
Here is what can happen. The physician starts heading down a path but it happens to be the wrong path. Each step is just a little incorrect but the small errors in logic add up. The physician, however, is more and more invested in the path with each step, eventually arriving at a certain – but incorrect – diagnosis. It becomes nearly impossible to shake the physician from his or her path even when there are clear signs that it is veering away from a correct answer.
So, what does he recommend? Repeatedly ask “What else might it be?” He found that this momentary pause forces the physician heading headlong down a rat hole to back up, reconnoiter, re-evaluate, and begin again. A correct diagnosis is, therefore, more likely. How much pain, expense, and suffering might you prevent over the course of your career by employing this tactic? Keep your mind open to other answers even when you are certain you are correct.
Here’s a third and final question; this is the one you should regularly review with a mentor:
How would you like to be remembered?
I recently spoke to a group of first year medical students and asked whether they viewed Medicine as a calling or a job. Happily, they all responded that they saw their careers as a calling – a special opportunity to help people and make a difference in the world. Then I asked them, “So, how many of you know doctors who apparently look at Medicine as a job?” The hands all went up again.
What turns the idealism of the first year medical student into the perfunctory job performance of the seasoned physician? There are studies demonstrating that with each stage of medical school and residency training, people become less and less empathic. In the interest of full disclosure, medical students with the lowest empathy scores are most likely to end up in surgical fields like mine.
There are minefields out there, my friends. We are not immune to depression and substance abuse. Coupled with knowledge of how to keep others alive, we apparently know a lot about how we might kill ourselves. About 400 US physicians take their own lives each year; that’s the equivalent of two entire classes at MCW.
We all know workaholics, right? Well, workaholism – for better or worse – is real and is the only addiction we celebrate. This addiction and its celebration are dangerous. We learn during our education about the importance of self-care but the hidden curriculum pushes us to work harder and harder. It drives a wedge between our idealism and our need to satisfy metrics and increase our work output.
Work is rewarding and good, of course, but so is the ability to shape the work we do. Finding ways to reflect, be creative, and nurture others – be it family, children, colleagues, or friends – brings joy and recovery. Like the runner who finds that she completes a race more effectively when she mixes running with walking, we need to take control of our lives and pace our work.
Back to the question: How would you like to be remembered? A group of interns was asked to write a speech that a colleague might deliver at a dinner honoring them at their retirement thirty-five years from now. You can imagine the responses. They did not hope to be remembered as the one who generated the greatest number of work-units or had the nicest collection of toys. They didn’t want to be celebrated for never being home. Instead, they hoped others would admire and remember them for their character and their idealism. They planned to reach their goal by listening to patients’ stories, being compassionate, and focusing on being present where they were most needed.
How do you keep focused on your goal? Find mentors who help you stay the course. Remind them of your goals and ask them how you will be remembered. Listen to those people.
So, my young colleagues, can you remember the three questions? Here they are again:
Is there anything else you would like to talk about today?
What else might it be?
How do you want to be remembered?
And, of course:
Congratulations!
Smell the roses!
and
The sky’s the limit!
[People look up from their phones...Light applause...Ceremony continues...]
